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Burntatt County Office of Zoning Administrator <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMITfil 3 � <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and '� <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the ,� c <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws nd 3 ;r) <br /> regulations of the State of Wisconsin. r <br /> ...$./......1�..... /T L �4 T - m <br /> t .....v../..... ..(!................................................ ................ ..t/.�...�1.............. .y .-. ......................... <br /> OWNTRACTOR or SURVEYO <br /> ER I�P/lease printh CONR or AGENT <br /> ..X.3...7.5...!Ur..Ch C.h..A.K.7.............. 'a 'S <br /> AODRES / -y- ADDRESS <br /> ................................................................................. ...... <br /> ADDRESS ADDRESS <br /> ........................................................................................... ..................................................................................... ...... �1 i <br /> PHONE r` PHONE "W <br /> :V: <br /> ... . .. . ..5................................................... . . . .............................................................................. ...... <br /> .. <br /> PL ..B L:R .!.I. WELL DRILLER :fir' : b <br /> . . ... . ....................................................................... ...... .p <br /> ADDRESS ADD.. .. R..ES..S m 0 <br /> � o <br /> c <br /> ........................................................................................... <br /> ... ...................................—...................................... ...... O .i <br /> PHONE PH..ON....E Z N r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms ' o <br /> New Building .......... Type of nstruction: No. Bedrooms ... ..... <br /> V '.nG to Septic Tank Size Gals. ... ...... <br /> Addition ...fY..... .......... ..... . ................... .. , .� .< <br /> Sanitary ...�x...... Size ....l.i� ft. x ....�.k... ft. . . :5.:.� <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: 4—: <br /> Movinc Soil Type ........................... . ...... r <br /> g .......... Area .................................... <br /> Mobile Home ....... Slope ................................... ...... :o / <br /> .......... <br /> Privy ,,,,,,,,., 3. Use (describe exactly ' Perc. Rate ............................ ...... i <br /> 1 -family <br /> Well home,garage,motel, etc. Dry Well ... <br /> SubdivisionSeepage Trench Z <br /> ... <br /> Camping Unit .......... Privy ... ..... .4) :� <br /> .................................................... Seepage Bed /. :xa4 <br /> ------------------------------------------------------------------- -- w ;6� .y <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. � :r <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at .UZ •/� <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersect on. UU `- <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. - <br /> ___________________________________________________________________ _ <br /> 5. Lot Size: Fig. A. 6. Location:................ ft. x .............. ft. - ............................... sq. ft. ....................................................................... ....... :9 <br /> O 7 <br /> O <br /> 70 <br /> n <br /> M <br /> I}{ Z �C <br /> o T <br /> A` <br /> d <br /> b <br /> M <br /> (� X .(n -oNr D W co -0 <br /> 0 »Q < > >0 B m <br /> T. PO m n n <br /> O Vi `G f/i on 10 <br /> O w O D <br /> u Nn ' <br /> „ n : y <br /> o c m <br /> a : S <br /> : <br /> o , <br /> C <br /> .. ..or..A..geC.n...a...z...l.........-............... ............ <br /> ....Da.t.e................. <br /> S . .... ....................... ....................................................................................Rema1� ........... 'rx' aAeA <br /> : O <br /> o . . <br /> .......................................................................................................?ganted <br /> o <br /> Inspection Date .7`t/.".. `......... ....... .. PO W N) o o " m <br /> . . ... . .. .. .................... . <br /> Zoning Ad istrator 8 8 8 8 8 rn <br /> rn <br /> NOTE: A preliminary site inspection must be made and site appon all structures involving sanitary facilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this appli ation before a permit will <br /> be issued. Do not purchase or install a septic tank, do any plumbing or start any building until a permit has been issued. A permit may be <br /> revoked it misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or pecifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APF ROVED. <br />